Provider Demographics
NPI:1881205078
Name:HERNANDEZ, DAGOBERTO JR
Entity Type:Individual
Prefix:
First Name:DAGOBERTO
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15901 VIEWPOINT RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5774
Mailing Address - Country:US
Mailing Address - Phone:760-333-1933
Mailing Address - Fax:
Practice Address - Street 1:255 E RINCON ST STE 219
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1387
Practice Address - Country:US
Practice Address - Phone:714-454-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician